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s12887 021 02814 W
s12887 021 02814 W
s12887 021 02814 W
Abstract
Background: Salmonella infection presents itself in a wide variety of ways, ranging from mild self-limited illness to
severe systemic disease with multiorgan involvement. Acute pancreatitis (AP) is a very rare complication that is
associated with Salmonella infection, especially among the pediatric population.
Case presentation: A five-year-old boy presented with a two-day fever and experienced vomiting, diarrhea, and
abdominal pain. The boy was admitted as a case of acute gastroenteritis, and Salmonella was found in his stool
culture. The severity of his abdominal pain during his hospital stay indicated the possibility of AP. A clinical
examination and blood workup were performed and showed significant elevation in amylase and lipase, which
confirmed the diagnosis of AP.
Conclusion: Although abdominal pain is a common presentation of Salmonella infection, the possibility of AP must
be considered when the pain is severe and the characteristics of the pain are suggestive of AP. Herein, we report a
case of AP complicating Salmonella infection in an immunocompetent child.
Keywords: Salmonella gastroenteritis, Pancreatitis, Amylase, Lipase
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Al Kaabi et al. BMC Pediatrics (2021) 21:353 Page 2 of 6
only. Further, it is not uncommon for AP to lead to paracetamol and nonsteroidal anti-inflammatory drugs.
death if left untreated [4]. He continuously spiked a high-grade fever with worsen-
AP complicating Salmonella gastroenteritis is a rare ing diarrhea that was associated with tenesmus.
complication among the pediatric population. This com- The examination revealed that the child was highly fe-
plication has been reported in adult patients with ty- brile (temperature above 39 °C) and tachycardic with
phoid fever and nontyphoid Salmonella infection, but normal blood pressure. His abdominal examination re-
there are few reported cases in the pediatric population vealed severe tenderness throughout the abdomen, but a
[7]. Herein, we report a case of AP complicating Sal- detailed examination could not be performed, as the pa-
monella gastroenteritis infection in an immunocompe- tient was in severe pain and refused to be examined.
tent child. The possibilities of an intra-abdominal abscess, acute
pancreatitis, surgical abdomen, and bacterial colitis were
Case presentation considered at that stage, and further investigations were
A five-year-old boy, previously healthy, presented with a conducted to identify any serious pathology. His WBC
two-day history of fever and experienced vomiting, diar- count remained normal for his age, with a count of
rhea, and abdominal pain. Although his fever was high, 6000/ml (4500–13,500/ml) that mainly showed neutro-
it was not associated with chills or rigors. Vomiting was phil predominance (62%) and immature cells (4%). His
frequent but not projectile, nor was the vomit bilious or hemoglobin dropped to 9.9 g/dL (11.5 g/dL), and his
mixed with blood. The diarrheal stool was watery in na- platelet count remained normal. His C-reactive protein
ture and mixed with mucus, but no blood was detected. (CRP) concentration was checked and was significantly
The abdominal pain was severe and colicky in nature, lo- elevated, with a value of 120.6 mg/L (Normal Range: 0–
cated in the epigastric area with no radiation. The pain 5 mg/L) [8]. His renal and liver function parameters
was relieved by passing stool, with no other pain- remained normal, and his bicarbonate level improved
relieving factors, including pain medications. Further, from 14 mmol/L to 19 mmol/L (22–26 mmol/L). Pancre-
the pain was aggravated by food intake. No abdominal atic enzymes were elevated, with an amylase level of 101
distension, no history of drug ingestion and no recent units/L (Normal Range: 25–101 units/L) and a lipase
travel. level of 169 IU/L (Normal Range: 3–32 IU/L) [8]. An ab-
A physical examination on admission revealed a highly dominal ultrasound (US) was performed to rule out
febrile child with a fever reaching 40 °C, tachycardia and intra-abdominal pathology and showed a small amount
otherwise normal vital signs. He also showed signs that of free fluid in the lower abdomen (mainly in the left
indicated moderate dehydration. His physical examin- lower quadrant), with an estimated volume of approxi-
ation, including an abdominal examination was mately 20 mL and few prominent mesenteric lymph
unremarkable. nodes (Fig. 1). The pancreas was visualized and appeared
Blood investigations revealed normal complete blood normal. Mild pelviectasis was also detected, with a diam-
count, with normal renal function and electrolytes. eter of 1 cm and a mildly prominent proximal left ureter.
Blood and urine cultures were also normal. He had low At this stage, the patient was treated as a case of AP
bicarbonate level of 14 mmol/L (Normal Range: 22–26 following the standard protocol of nil per os and IV an-
mmol/L) and the rapid antigen detection test was posi- algesia to control his pain. The possibilities of an intra-
tive for Group A streptococcal (GAS) infection. Table 1. abdominal abscess and surgical abdomen could not be
The patient was admitted with the suspicion of GAS ruled out; therefore, the antibiotic was upgraded from
infection (tonsillitis), and his abdominal pain was attrib- penicillin to piperacillin-tazobactam to provide wider
uted to mesenteric adenitis, which is usually associated coverage for gram-negative enteric organisms and anaer-
with GAS infection. The patient was started on intraven- obes. A surgical consultation was obtained, and the sur-
ous (IV) hydration and penicillin G sodium. Further, the gical team chose supportive management.
patient did not have a sore throat at that stage, and his On the sixth day of his hospital stay, the patient still
clinical examination did not reveal any sign of GAS experienced severe abdominal pain; therefore, the ab-
tonsillitis. dominal US was repeated, together with an abdominal
On the second and third days of his hospital stay, X-ray. He was scheduled for computed tomography of
the patient continued to have a high-grade fever, abdom- the abdomen on fourth day of admission to rule out any
inal pain, and diarrhea, but his pain was controlled with serious pathology that could have been missed by the
IV paracetamol. US, but the family refused the procedure. Abdominal US
On the fourth day of his hospital stay, the patient’s showed a fluid pocket of 11 cc in the left iliac fossa
abdominal pain worsened, and he complained of severe (which is an improving compared to the previous scan)
abdominal pain localized to the epigastric area. This pain and another 8 cc pocket of fluid on the right side, with
was aggravated by food intake and relieved by IV small para-aortic and mesenteric lymph nodes that were
Al Kaabi et al. BMC Pediatrics (2021) 21:353 Page 3 of 6
Fig. 1 Abdominal US showing a small amount of free fluid (20 ml) in the lower abdomen (mainly in the left lower quadrant)
most likely reactive as per the radiologist report. The ab- abdominal pain and diarrhea. Later, the patient was dis-
dominal X-ray showed gas distension of the transverse charged home with full recovery and with a close follow-
colon, with no other abnormalities (Fig. 2). Additionally, up with gastroenterology, infectious disease, and general
pancreatic enzyme analysis was repeated at this stage to pediatric teams. The patient presented to the outpatient
check the trend, and upward trends in both enzymes clinic for follow-up, and he was completely well with no
were indicated (amylase increased from 101 units/L to further concerns. US repeated on day 15 of illness (out-
131 units/L (25–101 units/L) and lipase increased from patient setting) showed a complete resolution of the
169 IU/L to 293 IU/L (3–32 IU/L)). A test of CRP levels fluid pockets that were seen before.
was also repeated and showed an upward trend, from
120 mg/L to 123 mg/L (0–5 mg/L). Blood and urine cul- Discussion and conclusion
tures were negative at this stage. The most common clinical presentation of salmonellosis
The patient’s condition continued to be managed as a is acute enteritis, in which the child will present with an
case of pancreatitis. The gastroenterology team’s input abrupt onset of nausea, vomiting, abdominal pain and
was requested at this stage, and they recommended con- cramps, located primarily in the periumbilical area and
tinuing supportive management, monitoring the trend in right lower quadrant. This stage is typically followed by
amylase/lipase on a daily basis, and considering starting mild to severe watery diarrhea and sometimes by diar-
a free fluid followed by a fat-free diet. The patient was rheal stool containing blood and mucus. A large propor-
started on IV morphine for better pain management and tion of children with acute enteritis are febrile, although
omeprazole to avoid stress-induced ulcers. younger infants may exhibit a normal or subnormal
On the seventh day of his hospital stay, the patient’s temperature. Salmonella gastroenteritis can be associ-
abdominal pain and diarrhea started to improve, and his ated with acute dehydration and complications that re-
stool culture was reported to be positive for Salmonella sult from delayed presentation and inadequate treatment
group B. Repeated amylase analyses initially showed an [1].
upward trend but then trended down (day 15 of admis- A total of 1–5% of children with Salmonella gastro-
sion), and repeated lipase analyses showed a downward enteritis can develop transient bacteremia. Following
trend (day 11 of admission), correlating with clinical im- bacteremia, salmonellae have the propensity to seed and
provement (Fig. 3). Repeated inflammatory marker cause focal supportive infection of many organs. The
(CRP) analyses showed a downward trend, from 123 mg/ most common focal infections involve the skeletal sys-
L (0–5 mg/L) (on day 6 of admission) to 13 mg/L (0–5 tem, meninges, intravascular sites, and sites of pre-
mg/L) (on day 11 of admission). existing abnormalities [1].
Thereafter, the patient continued to show gradual im- Acute pancreatitis complicating Salmonella gastro-
provement in his abdominal pain, fever, and diarrhea, enteritis is a rare complication among the pediatric
and he was gradually started on a regular diet. His fever population [7]. This complication has been reported in
subsided on day 11 of the hospital stay, as did his adult patients with typhoid fever and nontyphoid
Al Kaabi et al. BMC Pediatrics (2021) 21:353 Page 4 of 6
Salmonella infection, but there are few reported cases in acute pancreatitis could be regarded as a complication of
the pediatric population [7]. Salmonella infection [9].
Most cases of Salmonella gastroenteritis are associated Boyd [10] mentioned that necropsy on some patients
with biochemical pancreatitis that is characterized by an who died from Salmonella food poisoning showed subtle
acute elevation of serum amylase and lipase without diffuse acute interstitial pancreatitis. Since these patients
clinical correlation. However, there is no agreement that died from bacterial or endotoxin shock, pancreatitis
Fig. 3 Trend in the pancreatic enzymes amylase and lipase over the course of the patient’s hospital stay
Al Kaabi et al. BMC Pediatrics (2021) 21:353 Page 5 of 6
might be one of the signs of multiorgan failure. Later, answer this question. In this case, abdominal CT was the
two studies were conducted retrospectively on patients diagnostic imaging method of choice and it is a superior
with Salmonella enteritis. Renner et al. [11] reported test compared to abdominal US that might have solved
that concomitant pancreatitis was observed in 62% of the confusion, but unfortunately, it was not done, as the
patients and that the course of pancreatitis was mild to family refused any further imaging.
moderate in most of the patients. Murphy et al. [12] In conclusion, although AP is a rare complication of
found that none of the 51 patients who presented with Salmonella infection in the pediatric population, general
Salmonella infection had clinically apparent pancreatitis, pediatricians should entertain, the possibility of AP when
and one patient had a mild elevation of serum amylase patient presents with severe abdominal pain mimicking
without clinical correlation. The interpretation of such the characteristics of the pain associated with AP. Early
inconsistent conclusions from both retrospective studies screening and intervention will lead to better outcomes
is not clear. by decreasing the mortality and morbidity rates associ-
Hermans et al. [13] studied 14 patients with typhoid ated with Salmonella infection.
fever and found that 7 patients had elevated serum
Abbreviations
amylase and lipase levels on admission, and 4 out of the AP: Acute pancreatitis; IV: Intravenous; GAS: Group A streptococcus; CRP: C-
14 patients showed clinical signs of pancreatitis. Baert Reactive protein; US: Ultrasound; CT: Computerized tomography; WBC: White
et al. [14] studied 31 patients with Salmonella gastro- blood cells; INSPPIRE: International Study Group of Pediatric Pancreatitis
enteritis and found that 22% of patients experienced an
Acknowledgments
elevation in serum lipase. In each patient, pancreatitis We thank the parents of the patient for allowing us to use the patient’s data
was mild with minimal changes in the US. On the basis and to publish this case report.
of these studies, we concluded that Salmonella infection
Availability of data and material
can be associated with chemical pancreatitis but not ne-
Not applicable.
cessarily with clinically evident pancreatitis.
The mechanism of pancreatitis in patients with Sal- Authors’ contributions
monella infection is not well understood, although SA drafted the manuscript, carried out the literature review, and prepared
the illustrations. AA performed the final proofreading of the manuscript. HA
hematogenous or lymphatic spread are the proposed helped draft the manuscript. All the above mentioned authors read and
theories. Direct penetration of the pancreas via the mi- approved the final manuscript.
gration of salmonellae to the pancreatic duct from the
duodenum and biliary tree is another theory, and finally, Funding
This work is not supported by any sponsors. No funding was required in this
it is also theorized that toxin-induced or immune- study.
mediated pancreatitis can be associated with Salmonella
infection [15] [16]. Declarations
Our patient had multiple reasons for his abdominal Ethical approval and consent to participate
pain. Although he tested positive for GAS, the history This case report was approved by the Ethics Committee of Tawam Hospital.
and physical examination were not supportive of such Written consent was obtained from the parents for the standard medical
care given to their child as described in this case study.
infection. Therefore, we believe that the positive rapid
antigen detection test indicated a carrier state rather Consent for publication
than a true infection. We also believe that the pain and Written informed consent was obtained from the patient’s parents for the
the high-grade fever in this patient may have been at- publication of this case report, images, and all information contained in it.
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